What is real community development?

healthworkerburnoutCommunity Development Questions December 2013

As mentioned in our newsletters, we are going to try to answer community development questions from readers.  If you have any questions about working in Aboriginal communities please send them in.

The two questions I received below are similar, so I will handle them both together.

Questions:

1.     “Any ideas on how to prevent Aboriginal health worker burnout, that occurs commonly in health workers working in communities?”

2.    “When a community has a health service on offer, opportunities and resources to use, why don’t some elders take action to improve their communities? (I’m sure there are many complex answers.) And then we are told that community development must come from within the community. How can passionate, committed outsiders like me help bring about change from within communities?”

What is real community development?

The writer of the second question is right when they say that “I’m sure there are many complex answers.” But at the same time, the answer can be simple. Sometimes things that we would accept as normal in our own society get lost when we operate in another, like Aboriginal communities. So let’s work through it.

Some general comments first

Community development must come from within the community. It is not development of the community if the community is not involved in bringing about the change that is needed.

But for change or development to happen, the people need access to good information so they can get answers to the questions they have. This is where most development in Aboriginal communities falls down.

Statutory authorities and even many Aboriginal organisations do not see the need to communicate well with Aboriginal people. The people end up severely marginalized and unable to make important life changing decisions about their own future in an informed way.

The people do not need prescriptive ideas preached at them; they need access to a whole range of information. Then they can begin to shape their own future. Without this, the people experience a kind of community violence.

Some will question how we can call this a form of violence?

Community violence

Missed communication as it occurs in many Aboriginal communities is a form of violence. I am not saying it is intentional – usually it is not, but it has become a cemented part of the relationship played out between the dominant Australian culture and Aboriginal people since the beginning of British Settlement.

In fact, failed communication towards many Aboriginal people has become so institutionalised that it goes completely unrecognized in most of mainstream Australia’s interaction with them. This makes it a form of community violence.

Australian and international law say that if a contract, legal agreement or consent is agreed to or given without the person understanding what they are signing or agreeing to, then it is an unconscionable, repugnant act and does not hold up in law. I would extend this to the situations where the dominant culture holds back information or does not put proper communication processes and programs in place, leaving the people with devastating life changing consequences.

For many Aboriginal people, there are times they are asked to agree to something or even sign legal agreements and they have little understanding of what is being asked of them. This is an act of violence carried out on them. They are left distraught and hopeless when they realise what has happened is due to what they have signed. At other times it seems information is deliberately held back from them and they find out the real situation when it is too late to correct it.

Many end up with fatal illnesses, early death, lost economic opportunities, unemployment, drug abuse, high levels of social violence and even imprisonment because no one has told them the laws that are now in play. Good communication is vital for a healthy society. When it does not happen it will devastate a community of people and leave them unable to take effective action.

We need to remember that the world that many Aboriginal people now live in is very different from the world they have known for many generations. It is not access to their traditional information that the people have problems with; it is accessing and understanding information about the mainstream, dominant culture world that is a problem for them.

It is the mainstream dominant culture information the people need and want access to, and the dominant culture has control over this information. Sadly, not many dominant culture people understand the problem so they continue to do very little about correcting it.

This problem of access to dominant culture information is key to understanding the answers to questions 1 and 2 above.

A culture of silence

Sometimes a community of people have been traumatised and locked out of dominant culture information for so long that they have entered a culture of silence. In this culture of silence the people have trouble speaking out or even communicating with the dominant culture. To move them out of a culture of silence, the people first need to learn how the world around them works.

Before they can learn about the dominant culture world, many will first need to be convinced it is possible. They will need to experience learning things about the contemporary world outside their own world of knowledge. They may have learnt very little about the dominant culture mainstream world and are now convinced it is impossible for them to learn such things. If we are facilitating this process, we will have to initiate things to help the people have good experiences and discover they can learn about the dominant culture world which now controls their lives.

Targeting the young

Many dominant culture people also believe that Aboriginal family and clan leaders cannot learn contemporary knowledge, so they target younger people to teach and bring about change in their communities.

We need to remember these older people were young once and were also targeted by the dominant culture over their elders. This dominant culture thinking is very paternalistic. It is the traditional leaders and teachers who are the best people to be taught things first; because it is their role in the community to be the teachers and instructors. It is strange to even have to talk about this, as many people say they want to respect Aboriginal culture, but then work in a way that does not respect it; by targeting children and youth first, or removing specific individuals from their communities for ‘elitist education’.

When traditional leaders and teachers are given new information, we find a lot more of this information is disseminated through the community and many other positive things flow from it. However, even using traditional leaders and teachers has its limitations that we will look at in a moment.

How can passionate, committed outsiders like me help bring about change from within communities?

First look at the community in a different way

The first thing we need to do is look at “community” in a different way. Development of a community needs to be the development of the whole family/community, not just one or two people from within the family/community. This is community development rather than the development of an elitist few. Usually the dominant culture takes one or two people, trains them up and then sends them back into the community to do the work that we should have done with the whole community in the first place. Elitist education and elitist development set up winners and losers within a family/community and is detrimental in several ways.

1)     It can destroy individuals. Access to education and information that others don’t have sets them up to become antagonists in their own family or community. When this happens they will usually fail and drop out of the picture.

How does this happen?

It is a basic reality of human dynamics that no community on earth respects their own people turning up with strange new information and telling ’their own’ how something works or the way it is. There is an old saying, “A prophet is never accepted in their own community”.

This new information the young person has will usually conflict strongly with the way the traditional healer or the family head sees things. Right away they have to break the normal level of respect for the elderly and become “little upstarts”. This inevitably sets up a conflict situation within the family/community where there are no winners – just losers. Sadly, new information is rejected along with the bad process; leaving the people further from where they need to be.

Prophets from within have never been accepted by their own community and it is the same in Aboriginal communities. It has been this way for thousands of years, and it is not going to change.

2) If the specially educated elite survive due to intense dominant culture support, they remain as superimposed antagonists – almost dictators – in their own community where they challenge and override the traditional leadership structures and laws of their own people, becoming a law unto themselves.

3) Where the outcome is either of the above, it splits communities by creating arguments at a family and community level. This takes energy away from developing the family/community and leaves them divided and depleted.

How do we prevent Aboriginal health worker burnout?

A true community development model involves training not just a few Aboriginal health workers, but working to move the whole family/community towards understanding the causation of disease and sickness. Real ‘health literacy’[1]. This does not have to stop the training of specialist health workers, but it can lead to these health workers being supported in real ways by the community.

To do this, we need to do health literacy with the whole community; teaching the whole community germ theory and about the immune system[2] and go on to further empower all or most of the people to understand cause and effect in relation to  disease and sickness. This process needs to start with the traditional healers, then the family heads, working down thought the rest of the family members and to the whole community.

This form of development or community education treats the community with the respect that it deserves; as a living, dynamic organism.

Some background

So in answer to  the question, ‘why don’t elders take advantage of available health services’, we should not expect the elders to turn up supporting the health clinic, because they are not health literate and have no idea what the health clinic is about. They might assume like the rest of the community, that sickness is caused by lawless people who do sorcery, evil spirits or sickness country, just like Westerners did before they learnt about germ theory. They might also believe that the clinic has magic medicines and if they were doing their job properly then everyone in the community should be healthy like they were in the past.

If health literacy was taught, including the cause and effect of disease and sickness, then you would have the elders’ whole support. You would not be able to keep them away from the clinic.

In fact disease and sickness would drop dramatically in the community as the people took control of their own health. Reliance on the clinic would also decrease and the health workers, both Aboriginal and non-Aboriginal, would not be overworked with everyone trying to get access to the magic medicines.

These are the results of real community development.

Support community education and development

We need to completely revise the dominant culture way of training and supporting a few chosen individuals. This is the dominant culture method that has been used since Captain Philip arrived here with the first settlers.

Captain Philip had Aboriginal people captured and then forced to learn. We could call it forced assimilation and we have continued doing it ever since in one form or another. Today we do it through elitist education in different ways. When a few Aboriginal people are chosen to go and learn the dominant culture ways so they can then go back and educate/change their own people, we have trouble seeing that the whole community needs to receive this information as a unit.

All communities have a social and political structure. When we come and do a form of forced social engineering by giving information to just a few, we throw the whole balance of that family/community out of order. We create change that is not sustainable and in fact very destructive.

Good Community Education

Over the years I have used the following process to do whole-of- community education in medical settings.

If a heart disease or heart attack patient asked for help, I get permission from the patient to talk to the whole family about it. If they had a traditional healer I start there, along with the family head. Most patients are happy for the family to know their situation.

However, when I do the education I start in a general way, talking about heart disease and about what a heart attack is. I do not talk about the patient’s condition as I work through the story unless the family head asks for specific information about the patient as I am working through it. After the people have a good understanding about the disease, the chances are they will want to work through where the patient is at. Sometimes they will do it without the patient being there.

Usually I have a separate session with the patient before the session with the family. If not, and the patient wants the information, I have a session with them and any other members of their extended family to work through their particular situation.

Most of us will have to work with a health worker, interpreter or other language assistant. Check with the patient and or the family head if it is OK for the person to attend as they might be from another family or clan. As in most human groups, people like their family information to be kept private. This is especially so in societies where people believe that sickness is caused by evil people who do illegal acts of sorcery. However, the story should come from you, not the interpreter, so it is coming from a source outside the community to the family. They need to hear the new information at the same time and come to a new understanding together as a group so there is no shame for anyone.

In this way we educate the whole family about heart disease or heart attack, giving the whole family the knowledge about the condition themselves and how to work with and support other members of the family that might have the disease.

If you then go on to do this same education with other families, you start to spread this information around the whole community. It is important not to talk about specific patients in general community education. As mentioned before, the respect of privacy is very important in Aboriginal culture.

I have Yolŋu families now tell me that the education I did with them many years ago has stopped other members dying of heart disease. I am also told by doctors that the whole family, elders and all, turn up for their checks and comply fully with the treatment offered.

The Cost of Education

Some people consider this type of development/education will cost too much. In fact, it costs much less than the way things are done at the moment – and it works. It empowers whole groups of people, changing their lives and giving them a chance for a real future. This kind of education impacts the next generation, saving money and lessening the burden on the health system.

Dominant culture people need real training

This method of doing community education requires different training for dominant culture people. We need trained dominant culture community educators or community development workers.

Some will respond to this statement by saying that we should be training Aboriginal people so they can do the education with their own people. There are two current and historically based approaches to education and training:

1)    Take Aboriginal people out of their communities and place them with dominant culture educators.

2)    Send dominant culture educators into Aboriginal communities to teach and train.

Sadly, in both these cases most if not all of these dominant culture educators/trainers have had no special training in language or cross-cultural communication; so they are unable to do their job effectively and efficiently.

I propose a third, more effective way that breaks free of the colonial model started by Captain Phillip. We can give dominant culture trainers and educators appropriate skills and training to go in and do community education with the whole community.

Conclusion

If we carried out this kind of community development,  Aboriginal health workers and dominant culture health workers would be less likely to experience burnout or be accused of doing sorcery, which sometimes happens. Elders would take action to improve their communities and passionate, committed outsiders would have more than enough to do to bring about positive change from within communities.

If you feel I have not answered the above question clearly or further questions have been raised for you in my answer, then please come back to me with another question. Dialogue is a powerful tool for learning.

 

Richard Trudgen

About Richard Trudgen

Born in Orange NSW, trained as a fitter and turner. Moved to Arnhem Land in 1973 one year for voluntary work, ended up staying 37 years, learnt language and trained in community development work. Wrote “Why Warriors Lie Down and Die” in 2000. Established Yolŋu Radio in 2003. Was CEO of ARDS Inc for 10 years. Developed discovery education methodology. Runs ‘Bridging the Gap’ seminars and training workshops, does conferencing speaking. Wants to build an e-learning school for Yolŋu people using both their own language and English so Yolŋu children and adults have a schooling system that works for them; plus one they can access anywhere. Trying to write my next book “When a New World Drops in on You”.

7 Comments

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  1. L C Jackson

    Dear Richard
    I am a Ugarapul (east coast) woman living in Sydney, so cannot speak at all about Yolnu, but I ask you to question an assumption in your article here: which is that you are assuming that western medicine has the answers to human health problems. Myself,living in the city, use western (mainstream) medicine only as a last resort. Why? because it has no interest in my quality of life; it is not holistic. Indigenous people prefer a human-oriented approach. There are many ways/systems of healing, of which the western system is only one.
    I do commend your work and wish you and especially Yolnu, well.

    Reply
    • Tim Trudgen

      Thanks LC for your critique on this point. This article was written in response to questions from medical professionals so it does work from a western medical world view. Richard is a strong believer in natural medicine and lifestyle based responses to illness. And like you say we believe in a holistic approach, in which western medicine must play an important role in healing in Australian communities

      Reply
  2. Shirley Melville

    Hi Richard, thanks so much for the sharing of the information. I live on the other side of the world and I am partly indigenous really us. You could not have said it clearer. I can totally relate to a lot of the issues/situations. I have been thinking about ways to resolve similar ones. Wow I have learn t and I am encouraged by the amazing job you have done. All best wishes.

    Reply
  3. David E. Forbes

    Correction – figures should have read:
    • Fifty –eight (58) sources reviewed were in the General category.
    • Seventy-two (72) were Cultural; and of these, thirty two (32) related specifically to Aboriginal primary care consultations.

    Reply
  4. David E. Forbes

    Engagement?
    Greetings all. Please forgive me if this is just a tad ‘techie’ but I have tried to limit my jargon.

    I have spent most of the past five years researching communications barriers and seeking workable solutions to improve patient and practitioner understanding, aiming to bridge the divide between the western dominated clinical style and the Aboriginal way of being, of learning, and of sharing health concerns.

    My target has been the development of what we call ‘assistive communications technology’ or ACT, in which a computing device such as a mobile phone provides ‘sense-making’ help by offering guidance in Aboriginal English, matching and interacting with Type 2 Diabetes clinical practice guidelines.

    Leaping forward to the intended outcome, the Aboriginal patient can touch the device and listen to an Aboriginal English speaking guide, yarning through a process that encourages the patient to identify and record signs and symptoms. This can be done at any time; and most usefully it would enable recording of experiences as they happen, not depending so much on memory recall in the sometimes stressful clinic consultation. The system for the doctor or nurse would help to ensure that misunderstandings are limited and the friendliness of the system would create a working bond between the parties. Why? Because it is designed to promote and support acculturation. It also allows faster exchange and storage of digital information. A patient sitting at home can send his or her signs and symptoms ahead of the primary care appointment; and download the consultation record for discussion with family and/or carer afterward.

    Acculturation is defined as: The modification of the culture of a group or individual as a result of contact with a different culture. This is a mutual, respectful engagement process in which domination has no place. It also reminds us that our communications failures are not all about language. Far from it. That is one of the big mistakes of health care service decision makers. It is about a mix of cultural barriers; and little progress (as the Closing the Gap inadequacies show) will be made in Aboriginal healthcare until this is fully embraced. Our technology tool concept, yet to be developed for use, is devised to provide a friendly ‘lingua franca’.

    In 2013 I reviewed 146 keyword-selected literature sources on the subject of patient-practitioner engagement. Sixteen of these were rejected after review, as lacking in sufficient detail.

    The 130 remaining were divided into General (non-intercultural) discussion of patient-practitioner interactions; and Cultural (intercultural) commentary on the same.

    The benefit of this ‘General’ category is that it looks at behavioural and institutional influences that may present barriers even between people of the same (mostly European origin) culture. The hope then was that this would recognize and resolve miscommunication that can occur due to westernized health care provider weaknesses without the cross-cultural complications being present.
    • Ninety-six (73.8%) of the literature sources were peer-reviewed, consisting of 91 Journal articles; four books and one doctoral thesis
    • The remaining ‘non-reviewed’ sources were made up of professional web articles and expert-source healthcare and cultural communications advisories and submissions.
    • Fifty –seven (58) sources reviewed were in the General category.
    • Seventy-one (72) were Cultural; and of these, thirty two (32) related specifically to Aboriginal primary care consultations.

    This was then sorted for academic purposes into headings and a table but the main objective was to identify Communications Barrier (Gap) Characteristics. These characteristics were then built into the computer mapping system and tested for readiness once a device application design process was commenced. The intention is to overcome these barriers by emphasizing their unwanted characteristics and providing navigation remedies. The seven key characteristics arising are listed here in order of priority, number one, Cultural Competence, being the most constant barrier occurring in the analysis.

    1. Cultural Competence – Navigation and negotiation design for two-way cross-cultural ‘cognitive consonance’ i.e. a mutually confident, shared understanding in and of the consultation
    2. Biopsychosocial – inclusion of psychological and sociological as well as biomedical knowledge
    3. Language – syntax simplification; Aboriginal English dialectal accommodation; interpreter engagement advice
    4. Beliefs – Extension of Cultural Competence. Recognition of role of Aboriginal holistic health including healthcare and death perceptions
    5. Education – further extension of cultural competence including Training/Retraining of Healthcare Providers & educational engagement with Aboriginal patients
    6. Family – inclusion of extended family and community terms and their relationship with individual member health/healthcare occurrences
    7. Time – Aboriginal concept of time and timing of health ‘events’. Time constraints imposed by the health care service system

    Sadly I have to advise that progress has been stalled due to lack of funding for the essential final stage. We were turned down by NHMRC on the grounds that it may not be commercially viable. (Another way of putting it is that the Aboriginal community is not big enough to attract commercial investors wanting to make money. I have to ask – what about SAVING costs in healthcare then?). In truth commercialization was not our aim but as grant funding dries up nationally, we have few options. Before this can be achieved, we have much work to do within rural and remote communities; and that may take years- or never.

    Reply
  5. Leo Boudib

    Thank you Richard, this was a pleasure to read. One day I will be doing more for the Real Australian communities directly. Until then I will continue to learn from your articles. Sincerely, Leo (Sydney)

    Reply
  6. Sue

    What a fantastic idea for a series of articles. I am not a health care worker but I am fascinated by and interested in learning better cross-cultural practice

    I’m doing a certificate in aged care at the moment and I have been dismayed sitting in a class with several migrants and/or disaffected Anglos who I knew were missing out on info because of the way the trainer didn’t seem to be able to put herself into their shoes and think a little about what she WASNT saying, what she was presuming about their knowledge and experience. And yeah, it felt like violence. It felt like the trainer was a little too intent on proving herself and showing her expertise so that it was better to throw a little “industry lingo”
    into her convos just so she could prove (probably unconsciously) that she was “better than us”. Us whitefellas still don’t get how violent out society is. Now our way of divide and conquer is killing the earth I guess we’re starting to. It’ll be good when that mindset dies.

    Looking forward to reading and learning more from you. Thanks for sharing

    Reply